Cargo Ship Pre-Boarding Medical Declaration Form
Personal Information
Full Name
Position/Rank
Nationality
Date of Birth
Passport/ID No.
Contact Number
Medical History
Do you have any existing medical conditions?
Are you currently taking any medications?
Have you experienced any of the following symptoms in the past 14 days?
Travel History
Have you traveled outside your country or been in contact with anyone diagnosed with an infectious disease in the past 14 days?
Declaration
I hereby declare that all information provided is true and complete to the best of my knowledge.
Signature
Date